Category Archives: 公共衛生 – Public Health

Albert Cheng says two recent cases of patients who died because they could not afford the costly drugs underline the need for doctors, not accountants, to decide which medication to prescribe

Time and again, we hear the sad news of patients dying of cancer or a rare disease because they have been denied the best that medical science could offer as they could not afford the costly drugs.

Single mother Chi Yin-lan, 36, had a rare genetic disease and passed away last month, just over a week after her emotive appeal to lawmakers for help. She left behind a 13-year-old daughter who also suffers from tuberous sclerosis complex, which causes tumours to grow in vital organs such as the brain and kidneys.

Chi specifically wanted an expensive drug for her disease to be included in a list of government-subsidised medication.

The government’s pronounced policy is that “no one should be prevented, through lack of means, from obtaining adequate medical treatment”. However, as Chi’s case has shown, this is far from the reality. Even if it is a matter of life or death, there is no discretion. Even if the attending physicians have approved of the use of drugs not on the list, they can only sit on their hands and watch their patients languish away.

Patient groups estimate that less than HK$400 million would be adequate to cover the additional drug bill for the 2,000 or so local patients with rare diseases. In contrast, the government’s budget surplus for last year alone was HK$92 billion.

Fung Kwai-kwan, 77, was another patient who died last week, from prostate cancer, after failing to obtain a new and expensive precision drug. There was no government assistance as the medication fell outside the scope of the current assistance programmes – the Community Care Fund’s medical assistance programme and the Samaritan Fund, both administered by the Hospital Authority.

Fung had sought help through a social worker, but was told flatly that he was on his own. Out of despair, Fung attempted suicide, but was saved. Finally, the NGO Against Elderly Abuse agreed to cover his costs. Unfortunately, it was too late and Fung died five days after he started taking the drug.

Cancer might have killed Fung, but the bureaucratic medical system contributed to his death.

Policies may be rigid, but the people enforcing them should not be. It is vital for the authorities to allow the doctor who best knows the condition of his patient to exercise discretion on prescribing the needed drugs in a critical situation.

Currently, patients who need medication not on the list of subsidised standard drugs must apply for help. Medical social workers will assess their financial status, with reference to their household income, expenditure and capital assets. If approved, a subsidy will be given through the Samaritan Fund.

In early 2011, the Community Care Fund was launched, aiming to expand the safety net to cover more drugs, especially newer ones. It adopts the same financial assessment criteria.

However, this is not enough. The Hospital Authority should give more weight to the expert opinions of the attending teams of medical professionals. If the medical team in charge is convinced that a certain drug not on the pre-approved list should be prescribed, its recommendation should be taken seriously, no matter the cost.

We must not sacrifice patients’ interests in the name of cost control or bureaucratic convenience.

The same principle of empowering the experts to make an ethical call should also apply in organ transplants. The government is poised to consult the public on whether to relax existing rules to allow an underaged person to donate organs for transplant. This follows the case of terminally ill patient Tang Kwai-sze, whose daughter was barred from donating part of her liver to her mother as she was three months short of the minimum donor age of 18. Fortunately, a 26-year-old woman stepped in and donated two-thirds of her liver for a transplant.

Professor Lo Chung-mau, head of Queen Mary Hospital’s liver transplant centre, insists that a definite line should be drawn on the age requirement. There are, of course, two sides to any ethical dilemma. On this matter, I would defer to the experts who know best, including Lo.

Yonden Lhatoo is appalled by what the tobacco industry and its political allies are doing to stop the government from upgrading warnings on cigarette packets

I was at a 7-Eleven convenience store the other day when two young women walked in to buy cigarettes. There was a bit of a hold-up at the counter because they wanted the packet with the least repulsive graphic warning label.

After some back and forth with a store clerk who was both amused and annoyed, they finally settled for one that didn’t remind them too much of what their internal organs will look like when smoking finally kills or maims them.

They, like many smokers in our city, may not be aware of it, but a suffocating war – unprecedented in skullduggery and Machiavellian manipulation – is being fought over their health in the city’s legislature. I’m talking about Hong Kong’s bid to slap bigger warning labels as well as more warnings on cigarette packs, along with a hotline number to help smokers quit.

Hong Kong is one of more than 100 jurisdictions to have put graphic warning labels on cigarette packets, but has fallen far behind many of its peers as there has been no upgrade since it started the practice in 2007.

The government finally tabled an amendment bill in the Legislative Council on Wednesday to increase the size of the warning label from 50 per cent to 85 per cent of every cigarette packet. Sounds simple enough, but try getting it passed by an already deeply divided legislature being lobbied and pressured, no holds barred, by powerful vested interests.

One of the world’s foremost anti-tobacco advocates, the irrepressible Judith Mackay, broke it down for me.

“The process has been toxic – I’ve never, in the last three decades, seen such opposition, lobbying or filibustering of a tobacco bill in Legco,” she said. “An army of tobacco executives, lawyers and their allies have descended on Hong Kong to try to obstruct, delay and prevent the legislation going through. One veteran legislator confided to me that he, too, had never witnessed such intense lobbying on any topic. He said that he himself felt the pressure and that this was having a ‘chilling effect’ on even those who were supportive of the bill.”

That’s quite something, coming from a tobacco-control expert whose global and Hong Kong-based campaigning against smoking has earned her death threats, offers of 24-hour police protection and the label of one of three “most dangerous people in the world” by the industry.

She also introduced me this week to another prominent anti-tobacco expert, Geoff Fong, who has been citing solid research evidence showing the effectiveness of bigger warning labels and the need to revise them so that the desired impact does not wear out.

Mackay’s rhetorical question summed it up: “With about 7,000 deaths a year from smoking in Hong Kong, should the tobacco industry and a few legislators be blocking a public health measure that involves no cost to government, and which works, and which will save lives?”

If the government’s inability to really take on the merchants of death stems from its lack of both will and political backing in the face of their money and influence, the maths still demands a far tougher approach. The cost of smoking to Hong Kong is estimated to be in the tens of billions of dollars every year, dwarfing the amount it reaps from tobacco duty.

What’s there to be so afraid of? Public opinion is in favour of clearer and tougher warnings on cigarette packs – 80 per cent of non-smokers, ex-smokers and smokers themselves support the move, according to the last count.

Probably not those two young women at the 7-Eleven counter fussing over the aesthetics of warning labels on their cigarette packets, but hey, there’s no denying the impact.

Geoffrey Fong says studies over the years and in many countries demonstrate the effectiveness of bigger warning labels and a ‘quitline’ in empowering smokers to give up, while motivating youth not to take up the harmful habit

Tobacco products cause more deaths in Hong Kong and throughout the world than any other single preventable cause. Governments have a legal and moral responsibility to warn its people about the extreme dangers of these products. Warning labels – particularly large warnings with graphic images – have been proven to raise awareness of the harm of tobacco and second-hand smoke, increase motivation among smokers to quit, and discourage youth from taking up smoking.

In 2007, Hong Kong became one of the first jurisdictions in Asia to implement graphic warnings on tobacco packaging, occupying 50 per cent of the pack. However, these warnings have remained unchanged on the pack for a decade.

But this is about to change. This week, the Hong Kong government is tabling a law calling for an increase in size of its warnings from 50 per cent to 85 per cent of the pack, doubling the number of warnings, from six to 12, and adding the hotline number for smokers who want to quit.

Studies from the International Tobacco Control Policy Evaluation Project provide evidence supporting these proposed changes. Beginning in 2002, the project has conducted research in 28 countries, covering over half of the world’s population, including China, South Korea, Thailand, Malaysia, India, Bangladesh, Australia and New Zealand within the Asia-Pacific region, to evaluate the impact of tobacco control policies. We have conducted over 60 studies of the impact of warning labels, and a number of these studies have measured what happens when governments revise their warnings, such as introducing graphic images, changing the positioning of the warnings on the pack, and increasing the size.

First of all, there is a clear need to revise the warnings in Hong Kong because of the “wear-out” effect – messages that are repeated over time lose their impact and need to be refreshed. The studies showed the wear-out effect of warnings across a diversity of countries, including Canada, the United States, Australia and Mauritius. Canada was the first country to introduce pictorial warnings in 2001, when it implemented 12 graphic warnings taking up 50 per cent of the pack. But from 2002 to 2011, noticing the warnings dropped by over 25 per cent, their impact on thinking about the risks of smoking dropped by 35 per cent, and the impact on thinking about quitting dropped by nearly half.

However, when Canada revised its warnings in 2012, including increasing their size from 50 per cent to 75 per cent of the pack, the number of smokers reporting that the warnings made them think about quitting doubled.

Hong Kong’s warnings have remained unchanged for nearly a decade, well beyond the two to three years that the World Health Organisation and leading authorities recommend as the interval for revising warnings. Indeed, of the 12 jurisdictions that had introduced graphic warnings by 2007, Hong Kong is the only one that has not revised them. Thailand has revised its graphic warnings three times; Panama has done so six times.

Second, there is strong research evidence corresponding with common sense that larger warnings have greater impact. Experimental studies conducted by the Canadian government demonstrated that increasing warnings from 50 per cent to 75 per cent, 90 per cent and 100 per cent enhanced their impact. Larger warnings were rated by adult smokers, youth smokers, and youth non-smokers as being more effective for communicating health risks, changing social attitudes towards smoking, reducing smoking initiation, and helping smokers to quit.

Countries that have increased the size of their warnings have been challenged by the tobacco industry. In a recent high-profile case, Philip Morris International brought a challenge against Uruguay under a bilateral investment treaty to nullify the increased warning size from 50 per cent to 80 per cent, claiming there was no evidence that increasing the size of warnings was effective. The dispute was heard by a panel of the World Bank’s International Centre for Settlement of Investment Disputes.

A study of the Uruguay warning labels, which was presented to the panel, found that the increase in warning size was associated with a significant increase in the impact of Uruguay’s warnings.

In July 2016, the dispute centre rejected the company’s claims, ruling in favour of Uruguay. It also required the company to pay all court costs as well as Uruguay’s legal defence costs.

Hong Kong’s proposal to add the “quitline” number to the warnings is also strongly supported by the international evidence. Studies from Canada, the Netherlands, Australia, New Zealand and Brazil show that adding the number to warning labels led to significant increases in call volumes. In turn, counselling programmes that have been implemented through such numbers have been shown to increase the percentage of smokers making attempts to quit and reduce the probability of relapse.

Warning labels are a proven effective, and cost-effective, measure for empowering smokers to quit and motivating youth not to start smoking. The long-overdue proposed enhancements to the warnings in Hong Kong are not radical – they are well-justified and have strong support from international studies. Their implementation will make Hong Kong a global leader once again in this critically important public health measure.

For those who believe that enhancing warning labels is inappropriate, this rhetorical question from a Canadian tobacco control expert is right on target: “What warning labels would be appropriate for a consumer product that kills half of its regular customers?”

Geoffrey T. Fong, PhD, is professor of psychology and public health at the University of Waterloo in Canada, and senior investigator at the Ontario Institute for Cancer Research. He is the chief principal investigator of the International Tobacco Control Policy Evaluation Project

Gary Cheung says the Hong Kong government shouldn’t have been so quick to ban officials from drinking the water at estates hit by the lead scare

The days following the opening of Hong Kong International Airport in July 1998 saw flight delays, passengers waiting hours for their baggage and the shutting down of operations of air-freight handler Hong Kong Air Cargo Terminals.

In early 1999, a report compiled by a commission of inquiry did not blame any officials. Another report released by a Legislative Council select committee held Anson Chan Fang On-sang, the chief secretary at the time, and three key airport officials responsible for the fiasco.

After the release of the two reports, a senior official told me that Hongkongers should not be too harsh with those officials named in the Legco inquiry as “they had done their best”.

My memories of what the official said were rekindled recently when Chief Secretary Carrie Lam Cheng Yuet-ngor defended “diligent civil servants” amid criticism of district councillors pressuring officials into drinking water from public housing estates where excessive levels of lead had been found.

Speaking in Legco during a debate two weeks ago on two motions to launch an inquiry into the contaminated water scandal, Lam said at least two officials had been pressured by district councillors into drinking allegedly tainted water.

Lam, who admitted inadequacies in the system of monitoring the quality of drinking water, said she had ordered officials not to be pressured into drinking the water, to safeguard the government’s dignity. Lawmakers eventually rejected the motions.

I have several family members who are retired and serving civil servants. I have no lack of respect for the professionalism and diligence of civil servants. And, there is no denying that some politicians have spared no effort to make political capital from the contaminated water saga.

But that doesn’t mean we should easily dismiss the worries of the public housing tenants who have had to use buckets to collect drinking water after excessive levels of lead were found in tap water in their neighbourhoods.

History is littered with examples of officials eating food or drinking water from troubled areas to boost public confidence and show concern for the people.

In April 1997, Taiwanese president Lee Teng-hui ate a pork knuckle before cameras to reassure his people who were plagued by an outbreak of foot-and-mouth disease that was devastating pig herds on the island. In October 2013, Japan’s Prime Minister Shinzo Abe visited a fishing port in Fukushima, which was hard hit by the nuclear crisis in 2011, and ate locally caught seafood to demonstrate its safety.

Even some mainland officials will put themselves in the shoes of the people they govern. In July, Guangzhou mayor Chen Jianhua swam in the Pearl River to show that the water quality of the once heavily polluted river has significantly improved.

You may argue these men did so as public relations stunts and these incidents are different from Hong Kong officials being forced into drinking possibly contaminated water. But I can’t see what harm would be done if they did drink water before cameras to show their empathy with affected residents, as long as they did not do it under duress.

Undersecretary for Transport and Housing Yau Shing-mu and assistant Observatory director Sharon Lau Sum-yee were the two senior officials who drank from cups offered by district councillors in July. Yau, who grew up in a public housing estate, may know more about politics than Lam.

As the chief secretary claimed credit for having the “guts” to risk being criticised for seeking justice for civil servants, a chance for officials to show humility was squandered.
Gary Cheung is the Post’s political editor

James Nickum says the WHO standard is outdated, and we need to work to avoid a recurrence of the contamination at Hong Kong housing estates

It has been nearly a year since four out of 30 samples of drinking water in the Kai Ching Estate were found to have levels of lead in excess of the World Health Organisation standard of 10 parts per billion (ppb). The highest was 23ppb.

This revelation set off a circular firing squad of accusations and investigations centring on how lead solder, which has long been banned, found its way into the estate’s water pipes. Terms such as “scare”, “scandal”, “dangerous”, “crisis” and “toxic” filled the media and the speeches of politicians.

The government set up three task forces and the Water Services Department took thousands of samples at both “affected” estates and “unaffected” ones. On May 11, one of those task forces, the Commission of Inquiry into Excess Lead Found in Drinking Water, submitted its report to the chief executive. The government is now mulling over the results.

What tends to get ignored in all this hullabaloo is the magic number of 10ppb. Where did the WHO get this figure? What does it mean? Is 11ppb a scandalous figure? Is 9ppb safe? The answer in both cases would seem to be “no”.

Hong Kong is not Flint, Michigan, where some of America’s poorest people paid one of the highest rates in the country for water that, in some cases, exceeded the levels set for toxic waste (5,000ppb). It is also not the China on the other side of the border, where a 1984 WHO standard of 50ppb is still used.

It is not the US, where users are urged to take action if they discover 15ppb in their drinking water. If it is from their own pipes after untainted water is supplied from the mains, it is up to them to fix it, not the water agency. Over 40 million Americans are estimated to drink levels higher than this. Perhaps that explains the Donald Trump phenomenon.

Compared to a large part of the world, then, people in Hong Kong are actually more likely to drink tap water that is relatively free of lead. So is there cause for worry? Well, for many people, unfortunately yes, but probably not a lot.

The WHO relies on an expert committee, which goes by the acronym of Jecfa, to survey the current state of scientific knowledge regarding possible hazards to health. In 1986, the committee proposed a “provisional tolerable weekly intake” of 25ppb based on studies of infants that indicated they did not retain lead at levels lower than that. This works out to 10ppb for a 5kg bottle-fed infant drinking 0.75 litres of water per day, with the additional assumption that it receives half of its lead intake from somewhere else, such as old lead paint.

Since those other sources of lead have become less common in the past 30 years, and the standards were set for the most vulnerable in the population, 10ppb would seem to be an overly cautious standard. Even doubling that should not be a matter of great concern, possibly even for the most vulnerable populations.

Unfortunately, as the amount of lead we are exposed to has declined, the results from more recent scientific studies are far from reassuring. Lead in any amount appears to affect health to some extent.

Newer epidemiological studies reviewed by Jecfa in 2011 found that there are no safe levels. The old tolerable intake is not really tolerable. It is associated with a decrease of at least three IQ points in children and an increase in systolic blood pressure of three points in adults.

The WHO has kept the standard at 10ppb on practical grounds, not for reasons of health. There is little magic in this number. The only good lead in tap water is no lead. When it is detected at any level – but particularly over 5ppb – the cause should be determined and, to the extent possible, fixed.
In Hong Kong, the contamination came from the use of cheap but prohibited lead solder in the pipes

In Hong Kong, it has already been determined that the contamination came from the use of cheap but prohibited lead solder in the pipes of the estates. This all needs to be replaced, preferably by those who put it there, and oversight systems put in place to prevent a recurrence.

Life is filled with risks, some of which, like eating fast food or walking across a busy street, are our choice. Others, like the air we breathe or the water from the tap of a housing estate, are not. Some risks we know about and others we don’t.

Lead is a known health risk; what was not known was that it is in Hong Kong’s tap water when it should not have been. Now we know. It should not happen again. Think how smart and heart-healthy those of us who were raised in the days of leaded gasoline could have been!

Professor James E. Nickum is an adviser at the Water Governance Research Programme, University of Hong Kong